‘Gross failings’ in mum and baby’s home birth deaths

A mother who died along with her baby after choosing to have a home birth might have been saved if she was taken to hospital earlier, a coroner has found.

Jennifer Cahill, 34, died at North Manchester General Hospital on 3 June 2024, shortly after suffering a haemorrhage during her labour while giving birth to Agnes Lily at home in Prestwich.

An inquest at Rochdale Coroner’s Court heard there were “gross failings” in her antenatal care and from two inexperienced community midwives at her birth, who did not monitor the baby correctly.

Coroner Joanne Kearsley said both the child and mother might have been saved had taken action been taken sooner, and found both their deaths were contributed to by neglect.

Mrs Cahill had wanted a home birth and believed she was low-risk, but evidence heard during the inquest suggested she should be classed as high risk after losing “a lot of blood” during the birth of her first child in hospital in 2021.

Ms Kearsley said she should have been referred to a senior consultant who could have properly explained the risks of a home birth and might have prompted Mrs Cahill to have the birth in hospital or at a birthing centre.

Manchester University NHS Foundation Trust has apologised and accepted there were “serious failures” in the care given to Mrs Cahill and her child.

Kimberley Salmon-Jamieson, the trust’s deputy chief executive, said its home birth service had been remodelled to make it safer after the case led to an independent review.

“We will also study the Coroner’s conclusion very carefully to see if there are any further actions which we should be taking,” she said.

Speaking on behalf of the family, Claire Horton, a medical negligence lawyer, said: “Jen and Agnes’ deaths were entirely avoidable: they were both catastrophically let down by mismanagement before, during and after the birth.

“Jen was not properly counselled or observed.”

Mrs Cahill died from organ failure and cardiac arrest after suffering the haemorrhage, the hearing was told.

The coroner also found the two community midwives, Andrea Walmsley and Julie Turner, were inexperienced in high-risk home births and showed a “lack of understanding and confidence”.

Ms Walmsley had not met Mrs Cahill before and neither had read her birth plan, the inquest heard.

Ms Kearsley said: “Mrs Cahill’s blood pressure should have been checked every five minutes and a urine sample taken. But neglectfully, this wasn’t done.”

Agnes, the baby, was not breathing when she was delivered and had the umbilical cord around her neck.

The coroner said the midwives’ lack of monitoring of the baby’s heart rate, which had been slowing for up to an hour, was a “gross failure”.

She said a call to emergency services “should have been made immediately” at this point.

The inquest was also told resuscitation equipment had not been checked and an air mask they tried to use on the baby was broken.

However, the coroner said no training could have prepared Ms Walmsley for what was happening, and said she was in a “blind panic”.

Ms Horton said “comprehensive changes” had been made by the trust, but added that Mrs Cahill’s family were “deeply saddened that these changes have only been implemented following Jen and Agnes’ deaths”.